Discussion
The objective of our study was to address mental health symptoms among Dutch elite athletes and their coaches. The most prevalent mental health symptoms among athletes were psychological distress and alcohol misuse, with prevalence rates of 73% and 52%, respectively. Among coaches, the prevalence reached 41% for psychological distress and 53% for alcohol misuse. Recent adverse life events showed a significant association with anxiety, depression, sleep disturbance, alcohol misuse and disordered eating in elite athletes. Additionally, recent severe injuries showed a significant association with distress and sleep disturbance in elite athletes. Among coaches, no significant associations were found between potential contributing factors and mental health symptoms. Among elite athletes, 60% (totally) agreed that they could openly address their mental health issues within their team/sport while 53% still (totally) agreed that more attention is needed for mental health/guidance in their team/sport. As for the coaches, 60% (totally) agreed that they could openly discuss their mental health issues within their team/sport. Furthermore, 41% (totally) agreed that more attention is needed for mental health/guidance in their team/sport.
Prevalence rates in elite athletes
Compared with the research project conducted two cycles ago, our study shows different prevalence rates of mental health symptoms among elite athletes.5 6 The prevalence of mental health symptoms in 2017 reached 32% for distress, 45% for anxiety/depression and 6% for alcohol misuse,5 6 while in our study, the prevalence reached 73% for distress, 14% for anxiety, 17% for depression and 52% for alcohol misuse. Notably, different screening instruments were used to measure symptoms of anxiety and depression in these studies. However, in both studies, alcohol misuse was assessed with the same screening questionnaire, namely the three-item AUDIT-C questionnaire.22 A potential influential factor contributing to alcohol misuse might be the existence of underlying psychological symptoms, for example, depression and anxiety.29 Prior research studies suggest that alcohol consumption can offer temporary mood improvement and relief from stress.29 Notably, we observed relatively high prevalence rates for psychological distress in athletes, which is possibly due to the various stressors elite athletes are exposed to during their career, such as intense physical activity, injury, performance pressures, selection challenges and concerns related to retirement or transitioning out of sport.30 Our findings regarding anxiety, depression, sleep disturbance and alcohol misuse are in line with the findings of a recent study among Canadian elite university-level student athletes that used the SMHAT-1 as screening instrument.31 In comparison with another study that used the SMHAT-1 among US athletes, we found higher prevalence rates for mental health symptoms among Dutch elite athletes, for instance, 17% vs 5% for depression.32 These varied results are likely to be explained due to the potential variance in population characteristics.
Gender differences in prevalence rates in elite athletes
In our group of elite athletes, we conducted post hoc analyses to explore the prevalence of mental health symptoms separately for female and male elite athletes (not possible among coaches due to limited sample size). Among female elite athletes, the prevalence of mental health symptoms reached 83% for distress, 18% for anxiety, 23% for depression, 31% for sleep disturbance, 47% for alcohol misuse, 0% for drug misuse and 22% for disordered eating. Furthermore, male elite athletes reported 62% for symptoms of distress, 9% for anxiety, 11% for depression, 18% for sleep disturbance, 57% for alcohol misuse, 4% for drug misuse and 9% for disordered eating. Female elite athletes reported significantly higher prevalence rates for symptoms of distress (p=0.005) and disordered eating (p=0.049) than the male elite athletes in our study.
Prevalence rates in coaches
Two recent studies among coaches showed different prevalence rates for distress (10.3% and 19%), alcohol misuse (48.1% and 19%) and depression/anxiety (43.6% and 39%).7 8 In our study, the prevalence of mental health symptoms among coaches reached 41% for distress, 53% for alcohol misuse and 5% for depression/anxiety. It should be noted that there were differences in the usage of screening questionnaires or the implementation of different cut-off scores among these studies. The increasing prevalence rate for distress is potentially due to the wide array of stressors that elite-level coaches have to encounter because of the critical role they have in athlete’s achievements, potentially leading to adverse effects on their mental well-being.7 33 The limited number of studies as well as these mixed results emphasise that research on mental health of elite coaches is still in the early stages, highlighting the need for further research in this area.
Contributing factors and mental health symptoms in recent published data
In our study, we found that recent severe injuries had an association with distress and sleep disturbance in elite athletes. Also, recent adverse life events had an association with anxiety, depression, sleep disturbance, alcohol misuse and disordered eating in elite athletes. Our findings are in line with the existing literature, which demonstrates the potential intersection of injury, recent life events and mental health symptoms in elite athletes.1 2 This is a confirmation that the occurrence of any adverse life event in elite athletes and coaches should trigger further screening for the presence of mental health disorders.
Views and needs towards mental health resources and support
While the number of studies exploring mental health symptoms and related treatment seeking among elite athletes across various countries has increased, this is the first study exploring the view and needs of Dutch elite athletes and their coaches regarding mental health resources and support.34 35 In our study, 38% among Dutch elite athletes and 51% among coaches reported not knowing whom to approach within TeamNL/NOC*NSF to discuss their mental health symptoms while 53% among Dutch elite athletes, and 41% among coaches (totally) agreed with the need for more mental health/guidance in their team/sport. This is potentially due to the fact that mental health-seeking in general is known to be still low among elite athletes due to various barriers, such as stigma, low mental health literacy, negative experiences with mental health seeking in the past and busy schedules.35 36
Limitations
It is important to note that the mental health symptoms in our study were self-reported and therefore, mental health disorders clinically diagnosed by a medical professional were not under study. This approach may introduce subjectivity into the results and potentially lead to either an underestimation or overestimation of the problem’s extent. Recall bias may also have an effect on the results due to self-reported assessment. Our study contained anonymous recruitment and validated scales to enhance objectivity of the participants regarding their own mental health, as mental health symptoms often considered taboo in elite-level sports, which could also result in an underestimation of mental health symptoms.37 In our study, we were unable to conduct non-response analysis due to the recruitment process which involved blinding to ensure privacy and confidentiality. Hereby, selection bias may have been introduced, potentially impacting the external validity of our results, as it is possible that the Dutch elite athletes and coaches with a specific interest in mental health support were more likely to participate.
Moreover, our study did not include a reference group or comparison group from a non-athlete population. Hereby, the possibility to observe potential differences with the general population where limited. Lastly, the cross-sectional design of this study prohibits assessment of any causal relationships between the dependent and independent variables under this study. Another limitation of our study is the lower-than-expected response rate which may influence the generalisability of our results.
Recommendations for practice
Our findings indicate that mental health symptoms are prevalent among Dutch elite athletes and coaches, emphasising the need for continued attention and awareness. Standard care by sport medicine physicians and/or other mental health professionals that includes tackling and/or surveillance of mental health symptoms is necessary. The IOC SMHAT-1 should be used by sports medicine physicians and other licensed/registered health professionals during the precompetition period (ie, ideally a few weeks after the start of sport training) and when any significant event for an athlete occurs (eg, major injury/illness, unexplained performance concern, end of competitive cycle, suspected harassment/abuse, adverse life event and transitioning out of sport) to support athletes who are at risk for developing mental health symptoms while also enhancing their psychological resilience.9 Hereby, mental health symptoms could be detected early and treatment (if needed) could be provided which can improve quality of life, performance and prevent development of mental health disorders in athletes and coaches.9 The IOC Sport Mental Health Recognition Tool 1 can be used by athlete’s coaches, family members and other essential supports of the athlete to observe mental health symptoms in athletes, which can warrant help-seeking and subsequent assessment, education, and/or treatment if red flags would be identified.9 Educating athletes and coaches about the consequences of alcohol misuse should be prioritised.38 39 Because of the rising prevalence rates of alcohol misuse, such education can contribute to improving coping behaviours, as research revealed a bidirectional association between alcohol misuse and mental health symptoms such as sleep disturbance and anxiety.38 39 In addition, we noted a decrease in prevalence rates of symptoms of anxiety and depression, emphasising the necessity to maintain the focus and monitoring efforts that contributed to this decline. Therefore, increasing knowledge about prevalent mental health symptoms is crucial, as it can enhance mental health literacy. This is a global challenge among both the general population and elite athletes and their coaches.40 More attention should be directed towards mental health guidance within organisations like TeamNL/NOC*NSF. This way, athletes and coaches will know where and whom to approach to address their mental health problems so that subsequent support can be facilitated for both athletes and coaches. Moreover, this approach will allow for more insight on perspectives and needs of athletes and coaches.
Recommendations for future research
In future research, it is advisable to consider a longitudinal design involving a non-athlete population as well. This would involve implementing repeated use of the SMHAT-1 over an entire sports season or implementing the Oslo Sports Trauma Research Centre Questionnaire on Health Problems (OSTRC-H) to monitor mental health symptoms comprehensively.1 41 The OSTRC-H questionnaire serves as a tool for the longitudinal assessment and monitoring of health problems in athletic populations.1 41 In our study, no associations were found between potential contributing factors and mental health symptoms, indicating the need for further assessment in future research to explore the possibility of other potential triggering factors associated with mental health symptoms among coaches. Future research should also focus on understanding how psychological, social, cultural and triggering factors relate to the development of mental health symptoms and mental health disorders. A research project should be implemented where mental health symptoms and mental health disorders will be evaluated, as the occurrence of any adverse life event can precipitate the onset of mental health disorders. Furthermore, researchers should focus on testing interventions in different subpopulations in elite sports, as different contributing factors (eg, severe injuries, adverse life events), and different population characteristics within elite sports may need different support/guidance. Regarding the ongoing stigma that mental health symptoms may be perceived as a weakness, therefore, creating a barrier for treatment-seeking, effective anti-stigma intervention programmes should be developed and implemented in elite sports.42–44 This is an important step to overcome this barrier and for creating a destigmatising environment for athletes and coaches whereas mental health will be a necessity and form of self-care in elite sports.